RAers, can you prevent Rheumatoid Arthritis in your children?

Doc, I have had rheumatoid arthritis (RA) since last 10 yrs. I know this terrible disease inside out. It has ruined my life. I do not want my daughter to suffer from this. Can I do anything to prevent rheumatoid arthritis in her? Does science have any answer? Are there any meds/ strategies to prevent rheumatoid arthritis?

The words of my patient are still echoing in my mind. ‘Does science have an answer?’ For a long time, we were grappling with the best strategy to control RA. Hence, majority of the research was directed at this.

However, importance of the ‘pre-RA’ phase has been understood. ‘Pre-RA phase’ is the phase before the symptoms of RA actually appear. This phase is important from the preventive perspective.

We do know about a few proven strategies to prevent RA.

These include:

1) Smoking cessation — The risk of developing RA is about two times higher for male smokers than for nonsmokers. For women, the risk for smokers is approximately 1.3 times greater than for non-smokers. (We have seen this in detail previously)

2) Dental hygiene—Periodontal disease is a proven risk factor for RA. (We have discussed this previously on the blog)

3) Optimal body weight. This is a recent finding. We would soon have a dedicated blog post for this. As of now, aim at a healthy body weight to reduce chances of developing RA.

4) Adequate vitamin D intake.

A study specifically looking at the various risk factors for evolution of RA in those with family history is underway & should provide further insight.

So, RAers; your daughters need not suffer the way you did. We do have these definite, easy strategies to prevent RA in those genetically predisposed.

See a Dentist to control your Rheumatoid Arthritis!

You must be wondering from the title as to what a Dentist has got to do with control of Rheumatoid Arthritis (RA)! In fact, he has a lot to contribute & this is known since the ancient times. Hippocrates had stated that removal of bad teeth cures arthritis. In 1818, Benjamin Rush stated that rheumatism can be cured by removal of infected tooth.
Edward C Rosenhow went a step further & showed that injection of apical granuloma from extracted teeth causes arthritis in rabbits.

Mark Bartold, a periodontist and the director of the Colgate Dental Research Centre at the University of Adelaide recently presented his group’s study of mice with preexisting periodontitis & RA at the annual European Congress of Rheumatology. His experiments showed that mice with coexisting periodontitis and RA exhibited more severe joint inflammation than did the mice with just RA. The progress of RA in mice with both conditions followed a more rapid course than it did in mice with just RA or just periodontitis.

What is periodontal disease? The word periodontal literally means ‘around the teeth’. Periodontal disease means infection involving the tissues around the teeth i.e. gums & bone around the teeth. Bacteria in the plaque cause infection of the gums. The bacteria settle down in the space between the tooth & the gum forming a pocket & even destroy the underlying bone.

Recent studies & research has shown that the bacteria involved in the periodontal infection can give rise to anti CCP antibodies & may trigger/ worsen rheumatoid arthritis. Mark Bartold’s work on mice is just one of the studies. Those with gum disease have been found to have a 2.2-fold greater risk of RA than did the general population. Gersuk, V. H. & colleagues studied 6616 subjects from the Olmsted County, MN. They were assessed for periodontal disease, RA & anti CCP antibodies. The study clearly showed that mild to moderate periodontitis is a risk factor developing RA. Periodontitis & smoking were found to be associated with anti CCP antibodies.

So then, how would periodontal infection cause anti CCP antibodies or joint inflammation? Porphyromonas gingivalis is a bacterium associated with a dental infection known as periodontitis. This bacterium produces an enzyme called Peptidyl arginine deiminase (PAD). It is hypothesized that this enzyme produced by the bacteria in the oral cavity diffuses into the blood & reaches the joints. It acts on various proteins & citrullinates them. Once in the joints, it may lead to increased citrullination of proteins in the joint. The body recognizes these ‘citrullinated proteins’ as ‘non-self’ & launches an immune attack. Immune cells produce antibodies to these citrullinated proteins i.e. anti-CCP antibody.

Now, would that mean taking care of periodontal infection takes care of RA as well? Yes, indeed. That must have been the reason why Hippocrates & Benjamin Rush stated that taking care of dental infections cures rheumatism. The ameliorating effect of minocycline on RA could be due to its antibacterial effect on the dental bacteria.

Dr. Nabil F. Bissada carried out an elegant study in RA patients on DMARDs & anti TNF biologics. A group of patients was treated for periodontal infection & was compared with the group that was not treated for the same. Non-surgical periodontal therapy was found to have a beneficial effect on the signs and symptoms of RA, regardless of the medications used to treat this condition.

Thus, if you have RA-
Brush your teeth and floss on a regular basis.
See a dental professional twice a year.
If gum disease develops, consult a Periodontist.
If you have a close relative with RA, oral hygiene & dental care is extremely important as dental infection may increase your risk of developing RA in future.

1.Edward C Rosenhow J Dental Res 1919;1;205-265
2.Pre-existing periodontitis exacerbates experimental arthritis in a mouse model. Cantley D M, Haynes d R, marino V, P. Mark Bartold. Journal of Clinical Periodontology Volume 38, Issue 6, pages 532–541, June 2011
3.Molitor et al. Moderate to Severe Adult Periodontitis Increases Risk of Rheumatoid Arthritis in Non-Smokers and Is Associated with Elevated ACPA Titers: The ARIC Study” ACR 2009 abstract #1160
4.Periodontal Therapy Reduces the Severity of Active Rheumatoid Arthritis in Patients Treated With or Without Tumor Necrosis Factor Inhibitors. Bissada NF et al Journal of Periodontology. April 2009, Vol. 80, No. 4, Pages 535-540